There is a lot of talk in the press and the California State government about passing a healthcare plan this session. I have researched the major plans and found them to be much more than the brief descriptions of them in the press and projected by their promoters. There are some positives, lots of negatives, and one plan, the "single payer plan" (SB 840) that appears clearly dangerous to quality health care delivery. The scary thing is that it passed the legislature last session (but was vetoed by the governor), and it looks likely to pass again this session. There is a chance that such a veto could be overridden this year. Equally scary is my observation that doctors know next to nothing about these plans, and don't want to get involved. I have news for you: we have to get involved and help shape healthcare legislation or we will all be very, very sorry. Not onl y for our medical practices, but for the c itizens of California, including ourselves, when we want medical care.
I am going to start with what I view as the worst plan, with some real chance of passing, in the hopes of getting some physicians motivated to do something about it. The text of the plan should be read by everyone: REQUIRED READING! It is available at:
http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_bill_20070710_amended_asm_v96.html (87 pages)
This is a very brief description of a complex plan. It is called a Single Payer system for all residents of California, where residents are defined as being in California with the intent to reside here. It provides extraordinary medical, mental health, dental preventative care and treatment of disease, including transportation, medical equipment, post-hospitalization stays in SNF's for up to 100 days, and even treatment entirely by prayer. All without co-pays or deductables (for the first 3 years), except self referral to a specialist after first 6 months will be paid 100% by patient. It does not cover cosmetic procedures except restorative. It will be illegal for insurers to sell insurance in California covering benefits covered by state plan. If a provider accepts any payment from the state plan, they may not accept cash payment for services. There will be state contracting for al l pharmaceuticals and durable medical equipment. There will be an extensive system of new offices and boards to oversee healthcare delivery, headed by appointed Commissioner and that Commissioner's subsequent appointees. The system will negotiate with specialty society representatives to set rates, or set fees if unable to agree on rates. The system will negotiate rates separately with integrated delivery systems. Rates can be adjusted to help fill system's needs. The plan will require electronic medical records, referral system, billing and payment system. Referral criteria will be set by the state, and it will establish guidelines for treatment of conditions. There is much, much more. If there is over use of services, there will be adjustment of reimbursement to providers.
The other major plan, passed by legislature AB 8 (Nunez) was just vetoed by the Governor:
http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_0001-0050/ab_8_bill_20070910_enrolled.html (128 pages). It would have identified 3-5% of highest risk population eligible for state high risk pool; enrollment could not be denied; plans would be purchased individually. The remaining 95-97% of population must be accepted for one of 5 specified benefit commercial plans offered by private insurance companies to compete by the quality of providers, customer service, and cost. The commercial plans were to spend at least 85% of funds on healthcare. It would have expanded Medi-Cal eligibility up to 1.33x federal poverty level and add "undocumented" children. It would have expanded Healthy Families Program up to 3x the federal poverty level and added $22-$75 monthly premiums per family fo r 2.5-3.0x poverty level families. It had "best practice standards" and pay for performance in all plans. Employers were to pay at least 7.5% of Social Security wages (max $7312.50/employee) for employee health care, or pay to state pool. Businesses that were 3 yrs old or with 0-1 employees with payroll <$100,000/yr were exempted. It was estimated that 3.4 of 4.9 million (69%) uninsured would become insured. Physician extenders were to be encouraged.
The Governor's proposal has been presented in outline form and was recently revised. It can be viewed at http://gov.ca.gov/pdf/press/Governors_HC_Proposal.pdf and http://gov.ca.gov/pdf/gov/HealthCareReform_Details10.9.07.pdf
In it, all Californians must have at least minimum insurance: $5000 deductable; out of pocket maximum $7500 per person, and $10000 per family. Insurance is to be privately purchased for adults > 2.5x poverty level, children >3x poverty level, with guaranteed issue. It provides for Medi-Cal or Healthy Families for others, with graduated contribution of premium. Undocumented persons would be handled by county and Univ of Calif facilities. Health insurance must be offered by employers of 10+ employees (20% of businesses), or employers must pay a 4% fee if not offering health insurance. Hospitals are to pay 4% of gross revenues to fund the program. Insurers are required to spend 85% of funds on health care. Miscellaneous provisions include increase scope of practice of "physician extenders", combining workers comp and traditional insurance in phased fashion, mandatory electronic prescribing, electronic health data exchange in 10 years, pay for performance, and rewards for healthy behaviours.
In reading these plans, there are some good ideas, like having the state contract for medication prices, with contracted rates good for all residents, or guaranteed issue health plans, including high deductable plans. There is much danger, from my point of view, of all the state determined best practices, decisions re: criteria for referral to specialists, and economic rewards for using physician extenders and saving money, rather than for excellence in health care. Especially dangerous is the idea of offering unlimited healthcare benefits to all people declaring themselves to be residents of the state, and then cutting provider reimbursement when they discover that they are spending too much money.
I urge all health care providers to get involved in these issues. Contact your elected state representatives and express which plans and features would be beneficial, and which would not. Call their offices and ask to speak with the staff members involved with health care planning, and try to get a few minutes to speak with the representatives themselves. Even more importantly, talk to your friends and colleagues in different legislative districts and get them to do the same. The legislature has heard from lobbyists and election consultants on these issues, but not from practitioners like ourselves.
I strongly support the state contracting for pharmaceuticals, with contracted prices available to all residents, insured or not. I alson have proposed a plan, which I have called the "Affordable Healthcare Initiative" to help people without or with insurance get fairly priced healthcare, and I will be presenting the idea to the California Medical Association convention this month. This is meant to be a part of the solution, and I have described it in a new website, www.MakeHealthcareAffordable.org -Len Doberne, MD